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Note: When you use Non-Network providers, you must also pay any charges between the Allowed Price and the providers charges.
Charges over the Allowed Price are not applied to the Out-of-Pocket Maximum.
This summary is intended as a guide to the coverage provided, for a complete description of the coverage terms and limitations please refer to
the Summary Plan Description. In case of a discrepancy, the Summary Plan Description will govern.
Medical Insurance – GOLD PLAN
PPO Plan Summary
MEDICAL
SERVICES
Gold Plan
In-Network
Out of Network
Annual Deductible
$250 per Individual
$500 per Family
$1,000 per Individual
$2,000 per Family
Coinsurance
10% of Allowed Benefit
40% + Balancing Billing
Out-Of-Pocket
$3,000 Individual/ $6,000
Family
$4,000 Individual/ $8,000
Family
Preventative Care
Covered in Full
40% of Allowed Benefit,
Subject to Deductible
Physician Visit
Physician Office: $25 Copay
Specialist: $50 Copay
40% of Allowed Benefit,
Subject to Deductible
Emergency Room
(True Emergency)
$200 Copay (waived if
admitted)
Covered as In-Network
Hospitalization
10% of Allowed Benefit,
Subject to Deductible
40% of Allowed Benefit,
Subject to Deductible
Vision
Eye Exam
$15 Copay
Reimbursed up to $50
Rx
$50/$150 Deductible, then
$10/$20/$35
$20/$40/$70 for 90 day
supply
$50/$150 Deductible, then
$10/$20/$35
$20/$40/$70 for 90 day
supply